source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWME1.m@ 969

DVBCWME1 ;ALB/ESW MENTAL DISORDERS (except PTSD AND Eating Disorders) WKS TEXT - 1 ; 6 OCT 2000
 ;;2.7;AMIE;**34**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A. Review of Medical Records:
 ;;
 ;;B. Medical History (Subjective Complaints):
 ;;    Comment on:
 ;;
 ;;    1. Past Medical History:
 ;;
 ;;        a. Previous hospitalizations and outpatient care.
 ;;        b. Medical and occupational history from the time between last rating
 ;;           examination and the present, UNLESS the purpose of this examination
 ;;           is to ESTABLISH service connection, then the complete medical history
 ;;           since discharge from military service is required.
 ;;
 ;;    2. Present Medical, Occupational, and Social History - 
 ;;       over the past one year.
 ;;
 ;;        a. Frequency, severity, and duration of psychiatric symptoms.
 ;;        b. Length of remissions, to include capacity for adjustment during
 ;;           periods of remissions.
 ;;        c. Extent of time lost from work over the past 12 month period and
 ;;           social impairment. If employed, identify current occupation and
 ;;           length of time at this job. If unemployed, note in Complaints whether
 ;;           veteran contends it is due to the effects of a mental disorder.
 ;;           Further indicate following DIAGNOSIS what factors, and objective 
 ;;           findings support or rebut that contention.
 ;;        d. Treatments including statement on effectiveness and side effects
 ;;           experienced.
 ;; 
 ;;    3. Subjective Complaints:
 ;;
 ;;        a. Describe fully.
 ;;
 ;;C.  Examination (Objective Findings):
 ;;     Address each of the following and fully describe:
 ;;
 ;;     1. Mental status exam to confirm or establish diagnosis in 
 ;;        accordance with DSM-IV.
 ;;     2. Additionally, to allow evaluation by the rating specialist, describe
 ;;        and fully explain the existence, frequency, and extent of the following
 ;;        signs and symptoms, or any others present, and relate how they interfere
 ;;        with employment and social functioning:
 ;;           a. Impairment of thought process or communication.
 ;;           b. Delusions, hallucinations and their persistence.
 ;;           c. Inappropriate behavior cited with examples.
 ;;           d. Suicidal or homicidal thoughts, ideations or plans or intent.
 ;;           e. Ability to maintain minimal personal hygiene and other basic 
 ;;              activities of daily living.
 ;;           f. Orientation to person, place and time.
 ;;           g. Memory loss or impairment (both short and/or long term).
 ;;           h. Obsessive or ritualistic behavior which interferes with routine
 ;;              activities (describe with examples).
 ;;           i. Rate and flow of speech and note irrelevant, illogical, or obscure
 ;;              speech patterns and whether constant or intermittent.
 ;;           j. Panic attacks noting the severity, duration, frequency and effect
 ;;              on independent functioning and whether clinically observed or good
 ;;              evidence of prior clinical or equivalent observation.
 ;;           k. Depression, depressed mood, or anxiety.
 ;;           l.  Impaired impulse control and its effect on motivation or mood.
 ;;           m. Sleep impairment and describe extent it interferes with daytime
 ;;              activities.
 ;;           n. Other symptoms and the extent to which they interfere with
 ;;              activities.
 ;;
 ;;D.  Diagnostic Tests:
 ;;     1. Provide psychological testing if deemed necessary.
 ;;     2. If testing is requested, the results must be reported and considered in
 ;;        arriving at the diagnosis.
 ;;     3. Provide any specific evaluation information required by the rating board
 ;;        or on BVA Remand (in claims folder).
 ;;
 ;;           a. COMPETENCY:  State whether the veteran is capable of managing
 ;;              his/her benefit payments in the individual's own best interests
 ;;              (a physical disability which prevents the veteran from attending
 ;;              to financial matters in person is not a proper basis for a finding
 ;;              of incompetency unless the veteran is, by reason of that
 ;;              disability, incapable of directing someone else in handling
 ;;              the individual's financial affairs).
 ;;
 ;;           b. OTHER OPINION: Furnish any other specific opinion requested 
 ;;              by the rating board or BVA Remand furnishing the complete
 ;;              rationale and citation of medical texts or treatise supporting
 ;;              opinion, if medical literature review was undertaken.
 ;;              If the requested opinion is medically not ascertainable on exam
 ;;              or testing, please indicate WHY. If the requested opinion can not
 ;;              be expressed without resorting to speculation or making improbable
 ;;              assumptions say so, and explain why. If the opinion asks "...is it
 ;;              at least as likely as not..?", fully explain the clinical findings
 ;;              and rationale for the opinion.
 ;;     4. Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;TOF
 ;;E. Diagnosis: 
 ;;    Provide:
 ;;
 ;;    1. The Diagnosis must conform to DSM-IV and be supported by the findings
 ;;       on the examination report.
 ;;    2. If the diagnosis is changed, explain fully whether the new diagnosis
 ;;       represents a progression of the prior diagnosis or development of a new
 ;;       and separate condition.
 ;;    3. If there are multiple mental disorders, delineate to the extent possible
 ;;       the symptoms associated with each and a discussion of relationship.
 ;;    4. Evaluation is based on the effects of the signs and symptoms on
 ;;       occupational and social functioning.
 ;;
 ;;NOTE:  VA is prohibited by statute from paying compensation for a disability
 ;;that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, whether based on
 ;;direct service connection, secondary service connection, or aggravation by
 ;;a service-connected condition. Therefore, when alcohol or drug abuse
 ;;accompanies or is associated with another mental disorder, separate, to
 ;;the extent possible, the effects of the alcohol or drug abuse from the effects
 ;;of the other mental disorder(s). If it is not possible to separate the effects,
 ;;explain why.
 ;;
 ;;F. Global Assessment of Functioning (GAF):
 ;;
 ;;NOTE:  The complete multi-axial format as specified by DSM-IV may be required
 ;;by BVA REMAND or specifically requested by the rating specialist. If so,
 ;;include the GAF score and note whether it refers to current functioning.
 ;;A BVA REMAND may also request , in addition to an overall GAF score, that a
 ;;separate GAF score be provided for each mental disorder present when there are
 ;;multiple Axis I or Axis II  diagnoses and not all are service-connected.
 ;;If separate GAF scores can be given, an explanation and discussion of 
 ;;the rationale is needed. If it is not possible, an explanation as to why not is
 ;;needed. (See the above note pertaining to alcohol or drug abuse, the effects of
 ;; which cannot be used to assess the effects of a service-connected condition.)
 ;;
 ;;
 ;;Signature:                                        Date:
 ;;END